Fundamentals 2017B

A nurse is assisting with the admission of an adult client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

Pale, scaly skin

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take?

Put the client's bed in the lowest position

A nurse is reinforcing teaching with a new parent of an infant who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching?

I will remove all stuffed animals from my baby's crib.

A nurse in a provider's office is providing care for a middle adult client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend?

Take Vitamin D supplements

A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take?

Tell the nurses that this conversation is not appropriate.

A nurse is caring for a client who has breast cancer and expresses fear about the future. Which of the following responses should the nurse make?

You seem really afraid. Let's talk more about your feelings

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

You should cleanse your eye from the inner to the outer edge prior to putting in the drops.

A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching?

You should cover your mouth with a tissue when you cough

A client who is scheduled to undergo surgery tells the nurse that she does not understand the procedure and is reconsidering her decision to have it. Which of the following actions should the nurse take?

Notify the charge nurse of the client's concerns

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?

3 + pitting edema

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

Stand with your feet together and your arms at your sides.

A nurse is preparing to obtain a client's vital signs. When washing her hands, which of the following actions should the nurse take?

Turn off the faucet with a clean paper towel after drying hands

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take.

1. Assess the client's gag reflex 2. Position the client on his side with his head turned to the side 3. Place a towel under the client's head with an emesis basin under his chin. 4. Separate the client's upper and lower teeth with an oral airway device 5. Cleanse the client's mouth using a toothbrush

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care?

1. Keep the family updated about the client's status 2.Encourage the family to comb the client's hair 3. Tell the client's family what to expect as the client's death nears

A nurse is caring for a group of clients in a long term care facility. Which of the following actions should the nurse take to prevent health care associated infections for these clients?

1. Wash hands after removing gloves 2. Use antimicrobial hand gel after refilling the client's water pitcher 3. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs

A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh?

13.6

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

A client who has just experienced the death of his child

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

A client who has measles.

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. The nurse can disclose health information without the client's written permission to which of the following entities?

A physical therapist who is involved in the client's care

A nurse is collecting data from a client who is 2 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?

A purple-colored stoma

A nurse working in a community clinic is talking with an older adult client who states that his life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?

Ego integrity vs. despair

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following?

Actual loss.

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?

Ask the client what he already knows about meal planning.

A nurse is caring for a client who has a prescription for a high protein diet to promote wound healing following surgery. The client's religion prohibits eating mean on particular days. Which of the following actions should the nurse take?

Ask the dietitian to recommend alternative food choices for the client

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to sure client safety?

Attach a humidifier to the case of the flow meter

A nurse in a long term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

Choose a private room for the interview

A nurse is collecting data from a client who requires bed rest and reports abdominal discomfort. The nurse notes abdominal distention. Which of the following conditions should the nurse identify as an adverse effect of bed rest?

Constipation

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

Count the client's radial and apical pulses simultaneously with another nurse

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that she is afraid to go to sleep, fearing she will not wake up. Which of the following is a therapeutic response the nurse should make?

Describe your concerns about sleeping to me

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?

Do you consume pork products?

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting?

Guided imagery

A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Have you had small liquid stools?

A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?

I know i can change my advance directives if i need to in the future

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?

I should remove constrictive clothing prior to measuring my blood pressure

A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the clients indicates an understanding of the teaching?

I should turn on the ceiling fan to block out unwanted noise.

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?

I will place a gel pad directly above your pubic area before i place the probe

A nurse is administering an intramuscular (IM) injection to an adult client. Which of the following actions should the nurse take?

Identify the landmarks for the ventrogluteal site before cleaning the skin

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

Instruct the client to tilt her head forward while eating

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

It must be difficult facing this type of surgery.

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

Latex

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the priority action for the nurse to take?

Measure the client's gastric residual before each feeding

A nurse is caring for an older adult client who has advanced rheumatoid arthritis but seldom requests pain medication. Which of the following actions should the nurse take?

Observe the client for nonverbal indications of pain

A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions?

Orthopneic

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?

Please don't tell my doctor, but i am taking my partner's oxycodone

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following actions should the nurse recommend to include in the plan?

Support the client's feet with foot boots

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions should the nurse take to maintain the client's confidentiality while providing care?

Provide information to another nurse at change of shift

A nurse in an acute care setting is documenting postmortem care for a client. Which of the following information should the nurse include in the documentation?

Release of personal belongings form

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. To prevent the transmission of this infection to others, which of the following actions should the nurse plan to take?

Remove the cover gown in the client's room after providing care

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

Remove the staple from the skin after both sides are visible

A charge nurse is reinforcing teaching with a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?

Removing and inverting a lid before placing it onto a nonsterile surface

A nurse is documenting client care in a client's electronic health record. Which of the following statements should the nurse include in the documentation?

The client became short of breath when ambulating

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider?

The client has redness and warmth in his calf.

A nurse is checking a client's muscle strength. Which of the following techniques should the nurse use?

The client shrugs her shoulders while the nurse applies firm pressure over the midline of the shoulders

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority?

The client's output was 60 mL for the past 3 hr

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off her right left. Which of the following is the proper crutch gait for the client?

Three-point

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?

Tighten your stomach muscles

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Clean the perineal area at least once a day

A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

Urine specific gravity 1.045

A nurse is caring for a client who is receiving chemotherapy and has stomatitis. Which of the following actions should the nurse take to reduce the client's discomfort?

Use 0.9% sodium chloride solution to rinse the client's mouth.

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Use warm water when bathing the client.